O2096: Exploring Pediatric Cardiac Arrest Care in Community Emergency Departments: A Contextual Inquiry

Purpose/Objectives:

Purpose: Pediatric cardiac arrest (CA) is a low frequency event associated with high morbidity and mortality. Many pediatric CA patients present to the closest community ED (CED) for initial arrest or post-arrest emergency care. While adherence to established CA and post-arrest guidelines has been shown to improve outcomes, few studies have specifically explored opportunities for resuscitation system improvement in the CED setting. The perspectives of CED clinicians caring for pediatric CA patients can provide insight to the unique challenges that diverse community hospitals, with varying patient volume, pediatric readiness, and resuscitation systems, face. In this study, we performed a contextual inquiry among CED clinicians to elicit the determinants—both facilitators and barriers—of optimal pediatric CA management.

Design/Methods: Methods: Using the implementation science EPIS (Exploration, Preparation, Implementation, Sustainment) framework, this qualitative study employed multilevel, multidisciplinary interviews at five regional community hospitals with varying characteristics. Purposive sampling was utilized to recruit a minimum of five participants from each site. Semi-structured interview guides modeled on the EPIS framework domains were developed using both deductive and inductive reasoning. Content areas included intra- and post-arrest management, institutional preparation, and reflections on team performance. Interview guides were revised iteratively to reflect important emerging themes from initial interviews. Interviews were audio recorded, de-identified, and transcribed. Transcripts were coded using thematic analysis with both inductive (evaluating for a priori hypothesized themes mapped to the EPIS framework) and deductive reasoning (emergence of additional novel themes). Interview content was analyzed throughout the data collection period to ensure the sample size was sufficient to achieve thematic saturation within and across sites.

Results:

Results: We have completed 23 clinician interviews. Thematic analysis revealed the following emerging themes: variable resource availability, high cognitive workload, workforce education and retention, and protocolization. Facilitators to optimal pediatric CA management included pre-arrest briefing, a calm event leader, and quiet, clear communication. Barriers included overcrowding, technical difficulties (i.e. airway management, vascular access), and the added psychological stress of resuscitating a child. The most consistently reported knowledge gaps involved weight-based dosing and lack of familiarity with the pediatric code/airway cart. No sites employed pediatric post-arrest protocols and no interviewees reported having institutional post-arrest target clinical parameters. Nearly all interviewees described pediatric CA responses as very high resource utilization situations.

Conclusion/Discussion:

Conclusion: We identified multiple facilitators and barriers to high-quality pediatric CA and post-arrest management in CEDs. Potential high-priority targets for intervention include: 1) efforts to familiarize clinicians with pediatric resuscitation equipment and weight-based dosing and 2) developing protocols to standardize post-arrest management. Optimizing post-arrest management is especially important since meeting post-arrest guidelines is associated with improved outcomes. Our study team’s next step is to address these determinants of pediatric CA care in CEDs by performing implementation mapping with site champions.